Exploring experiences engaging in exercise from the perspectives of women living with HIV: A qualitative study

Objectives To explore experiences engaging in exercise from the perspectives of women living with HIV, specifically, i) nature and extent of exercise, ii) components that characterize exercise experiences, iii) facilitators and barriers, and iv) strategies for uptake and sustainability of exercise. Design Qualitative descriptive study involving online semi-structured interviews. Recruitment We recruited women living with HIV from a specialty hospital, community-based organization, and medical clinic in Toronto, Canada. Participants Ten women living with HIV who may or may not have engaged in exercise. Data collection Using a semi-structured interview guide, we asked participants to describe their experiences with, facilitators and barriers to, and strategies to facilitate uptake of exercise. We electronically administered a demographic questionnaire to describe personal, HIV and physical activity characteristics of participants. We conducted a descriptive thematic analysis with the interview data, and descriptive analysis (medians, frequencies, percentages) of questionnaire responses. Results Women characterized their experiences with exercise with six intersecting components: (1) culture, (2) gender, (3) HIV-related stigma, (4) episodic nature of HIV, (5) sense of belonging, and (6) perceptions of exercise. Facilitators to exercise included: aspirations to achieve a healthy lifestyle, using exercise as a mental diversion, having an exercise companion, and receiving financial support from community-based organizations to facilitate engagement. Barriers to exercise included: limited resources (lack of mental-health support and fitness resources in the community), financial limitations, time and gym restrictions, and cold winter weather conditions. Strategies to facilitate uptake of exercise included: creating social interactions, provision of online exercise classes, raising awareness and education about exercise, and offering practical support. Conclusions Experiences with exercise among women living with HIV were characterized by intersecting personal and environmental contextual components. Results may help inform tailored implementation of exercise rehabilitation programs to enhance uptake of exercise and health outcomes among women living with HIV.


Study design
We conducted a qualitative descriptive study involving online semi-structured interviews with women living with HIV in Toronto, Canada [33]. This study was approved by the University of Toronto Health Sciences Research Ethics Board (Protocol #40852) (See S1 File). We obtained verbal consent for participation in the study, which was documented by the interviewer on the consent form prior to the interview.

Patient and public involvement
This research involved a community-clinical-academic partnership involving women living with HIV, and HIV community organization and clinical settings. Specifically, we collaborated with an HIV community-based organization (AIDS Committee of Toronto), HIV specialty hospital (Casey House) and HIV clinic (Maple Leaf Medical Clinic) who facilitated recruitment of participants to the study. Furthermore, women living with HIV and community leaders in the field of HIV rehabilitation were involved throughout the study, specifically providing feedback on the interview guide and demographic questionnaire, engaging in a mock interview with the interviewer (NSG) to build skills and capacity of engagement with the study population, and facilitating knowledge translation opportunities of results with the HIV community.

Participants, recruitment and sampling
We recruited women (cis, trans, and gender-diverse) living with HIV, 18 years of age or older, in Toronto, Canada with access to technology to participate in an online interview. We recruited participants from a specialty hospital (Casey House), community-based organization (AIDS Committee of Toronto), and a medical clinic (Maple Leaf Medical Clinic) in Toronto, Canada using a recruitment poster.
We used purposive and snowball sampling (word of mouth) to recruit a sample of women living with HIV who did and did not engage in exercise to obtain diversity of perspectives and experiences with exercise. We defined 'engagement in exercise' using the Canadian Society of Exercise Physiology (CSEP) physical activity guidelines as currently accruing (at the time of the interview) 'at least 150 minutes of moderate-to-vigorous-intensity aerobic physical activity per week' [34]. Women who did not meet this criterion were classified as 'non-exercisers.' Participants were categorized as an 'exerciser' or 'non-exerciser' using a combination of quantitative and qualitative approaches, including responses to the demographic questionnaire and their interview data. Participants who were categorized as non-exercisers based on their interview data were further categorized into one of the following three options: 1) currently does not exercise, 2) currently does exercise but does not meet the CSEP guidelines, or 3) currently does not exercise but was meeting the CSEP physical activity guidelines at some point in the past.

Data collection
Interviews: The primary author (NSG), a female Master of Science candidate with experience in HIV and qualitative research conducted online semi-structured interviews using Zoom software for video communications [35,36]. Only the interviewer (NSG), and participant were present at the time of the interview. We used a semi-structured interview guide to explore the following areas: 1) nature and extent of engaging in exercise (i.e., frequency and intensity of exercise history), 2) components that characterize exercise experiences (i.e., social and cultural factors), 3) facilitators and barriers to engaging to exercise (i.e., practical considerations), and 4) strategies for future and sustained exercise engagement (i.e., ways in which to encourage women to uptake exercise) (See S2 File). Field notes were also taken during the interviews. All interviews were audio-recorded and later transcribed verbatim.
Demographic Questionnaire: After the interview, we electronically administered a demographic questionnaire using Qualtrics XM [37] to describe personal, HIV, health and exercise characteristics of the sample.
Participants received a $30 CAD electronic gift card as a token of appreciation for their participation in the study.

Data analysis
Interview data. We analyzed transcripts using a descriptive thematic analysis informed by Braun and Clarke to classify themes within the data [38]. The interviewer (NSG) transcribed the interview audio files verbatim and reviewed each for accuracy. The interviewer (NSG) created preliminary notes, and drafted participant summaries for each interview embedded with participant's characteristics and experiences with exercise. The interviewer (NSG) coded all transcripts line-by-line to establish a preliminary coding scheme that pertained to the study objectives. Co-authors (KKO, ML) reviewed a sub-sample of the transcripts and participant summaries. We defined and clustered the codes into broader categories and sub-categories. All authors met on 4 occasions to refine the coding scheme and discuss analytical interpretations.
Questionnaire data. We downloaded responses from the demographic questionnaire from Qualtrics into Microsoft Excel 2018 [39]. We conducted a descriptive analysis including frequencies (percent) for categorical variables and median (25 th ,75 th percentiles) for continuous variables to describe the characteristics of the participants.

Sample size
We aimed to recruit an estimated sample size of 12-15 participants to gain the perspectives of women living with HIV and provide depth for rich data analysis [40]. Past qualitative studies that explored experiences with exercise among adults living with HIV were able to address study objectives using a similar sample size [41][42][43]. Prefer not to answer 1 (10%) Has Children (n = 10) * 6 (60%) Live Alone (n = 9) 4 (40%) Highest Level of Education Completed (n = 9) Did not complete high school 1 (10%)  Table 2. Self-reported level of physical activity (n = 9).

Physical Activity Characteristic Number (%)
In this past week (7 days), did you engage in at least 150-300 min of moderate-intensity aerobic physical activity, or at least 75-150min of vigorous-intensity aerobic physical activity, or an equivalent combination of moderate-intensity and vigorous-intensity activity?

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Experiences engaging in exercise from the perspectives of women living with HIV: A qualitative study currently did not exercise but was meeting the CSEP guidelines at some point in the past, and two currently did not exercise.

Type, frequency and duration of exercise
Based on interview data, the type, frequency and duration of exercise engagement varied among the women living with HIV. Across all 10 participants, the most common type of exercise activity performed in the past week was walking (n = 6), and the least common was calisthenics and kick boxing (n = 1). Other activities included: cycling (n = 4) and group-based exercise like Zumba and yoga (n = 4). Frequency of exercise ranged from women who had not exercised in over 5 years (n = 1) to women who exercised every day of the week (n = 2). The duration of time the women exercised ranged from no exercise (n = 1) to seven or more hours a week (n = 2). See S3 File for further details of exercise frequency, duration and type.

Characterization of experiences with exercise
Six intersecting components collectively characterized and constructed experiences with exercise among women living with HIV: (1) culture, (2) gender, (3) HIV-related stigma, (4) episodic nature of HIV, (5) sense of belonging, and (6) perceptions of exercise (Fig 1). We describe the components that comprised exercise experiences with representative quotes below.
Culture. Women described culture as influencing their attitudes, values and behaviour to exercise. Culture was comprised of i) cultural expectations, ii) intersectionality of women and their social identities, iii) exposure to exercise, and iv) food diversity.
i) Cultural expectations. Participants spoke about the cultural expectations, which influenced their engagement with exercise. Expectations of women were associated with specific responsibilities and customs, specifically those of African and/or Black decent. Participants whom identified as Black or African expressed that their cultural background largely dictated how women engaged and perceived exercise, namely with prioritizing domestic and other cultural responsibilities over their own health. Regardless of living in Canada, one community member expressed that ethnic women may be socially inclined into respecting their native culture, which places boundaries on how exercise is experienced:  ii) Intersectionality of women and their social identities. A couple of women expressed that exercising was not important for some women of color who experienced intersectionality, where they faced multiple forms of inequality. Having dealt with challenges such as oppression from others as a racial minority, to experiencing stigma due to their HIV status, exercise as a result, fell to the bottom of some women's priority list: I find African women are affected differently than European women based on oppression. There's just more intersectionality's with women of colour. We have to deal with oppression. . . in Canada for women of colour going to the gym is not going to be their priority. It's not. Especially, if they're dealing with health, and children, and poverty, and racism and, maybe hiding that they're gay, or hiding their diagnosis from their family. Like, it just layers up, right? (P3) Another participant of ethnic minority also spoke about intersectionality in women living with HIV, and how it may limit their exercise experience: In women it's so many other issues. . .the cultural issues, the children, the financial, this-that, the other taboos of allowing-not allowing. Many things play-play a factor. . . (P9) iii) Exposure to exercise. Living in Canada also allowed one woman to become exposed to the benefits of exercise, where she was once not privileged in her native country. Having experienced that exercise can be a healthy self-management strategy, she was better able to understand the benefits of exercise, as demonstrated below: with education now I never talked about it like long time ago. . .also because of the culture or the exposure to know those benefits. . . let's say when I was still in my home country, but uh, since I've been in Canada, being exposed it to how exercising will uh, have uh, a positive impact on my immune system, my health. (P1) With readily access to internet in Canada as opposed to her home country, another participant of African-Black decent agreed that offering online exercise classes would be beneficial for women: Yeah, especially here in Canada 'cuz most people have access to internet. It's not like back home, so that-that would be easier. (P5) iv) Food diversity. Additionally, culture produces diversity in food, with one participant claiming that many ethnic women engage in unhealthy eating habits that are transferred to their children. This should further coerce women into reconsidering their relationship with food and consult one another to gain insight into portioning meals alongside working out to ultimately lead a healthy life: Another participant of ethnic minority, while not directly driven by culture, also conferred the importance of maintaining a healthy diet alongside exercise: Exercise also, that's why I told you, it go together with diet. . ..uh diet and exercise and the treatment because the treatment, diet, the food that we eat is a treatment too. Yeah, treatment. The food we eat is uh treatment for our body. (P2) Gender. Identifying as a woman, affected the ways in which some participants viewed and engaged with exercise. Gender was comprised of i) caregiving roles and competing priorities, ii) objectification of women, and iii) social norms that set expectations for women.
i) Caregiving roles and competing priorities. For some participants, competing priorities at some point in their lives, such as work or caregiving (i.e., children) took precedence over exercising: ii) Objectification of women. The objectification of women was viewed as the sexualization of women in fitness spaces and at large. One participant voiced her concern over the objectification of women's bodies in the context of weight-lifting: Well, especially with weights because I find there's a lot more-there's more girls now, but there's a lot of guys too. So, yeah in that sense, I don't like being looked at as a piece of meat . . .and that happens a lot. . . just getting that look or those cat calls and that kind of crap, I just could knock somebody out. (P8) Consequently, exercise was viewed as a source of strength, and a means for some women to defend themselves:

you get so strong, you can beat up those-those guys that are getting in the way or bugging down your life. (P8)
Similarly, another woman of racial minority also voiced that exercise gave her the power to defend herself against the threat of misogyny: As a woman, I'm 40% weaker than men and a lot of us women of color have been abused by misogyny for far too long. And, when you exercise, you build strength where you can take a weapon and balance it out. And, there's women right now as we speak in India that are learning how to fight with sticks and swords. (P3) iii) Social norms that set expectations for women. Participants stated that social norms set the tone for body image and beauty standards for women, and consequently encouraged them to engage in exercise to look a certain way. This influenced engagement in exercise as some women claimed to rely on social media to obtain their ideal body standards in hopes of looking like other women who post exercise material: Similarly, another participant confirmed that gender influenced their level of engagement with exercise: "Well, being a woman, I don't know, we have to look good, right?" (P10) The social norms geared towards women may also demand a traditionally 'feminized' approach to working out. This participant spoke on the negative stereotypes of women in body-building: Well, the-the-the social norms and bias about gender, about women working out, looking beastly, looking too manly, it's too unfeminine, it's unsexy, you know. So, it's always characterized, especially as looking beastly, you know. And-and-and unattractive. So, I've had to break through those norms and stereotypes. (P3) HIV-related stigma. Stigma, defined as negative beliefs and attitudes about people living with HIV, influenced participants' decisions to engage in exercise. For some women, issues related to stigma generated fears which resulted in i) HIV-related stigma as a barrier to exercise, whereas for one woman, it resulted in ii) HIV-related stigma as a motivator to exercise, as a means to alleviate frustration from stigma.
i) HIV-related stigma as a barrier to exercise. Both social and internal stigma around HIV emerged as a challenge, with some women voicing concerns for those who may fear exercising due to their HIV status: ii) HIV-related stigma as a motivator to exercise. While participants expressed the negative effects of stigmatization towards women living HIV and its discouraging impact on exercise engagement, one participant also voiced that exercise can be employed to offset the negative effects of stigma, facilitating her engagement in exercise: [Exercise] helps [women] deal with stigma and everything else that might be happening in their lives, you know? (P6) Episodic nature of HIV. Women living with HIV revealed that they experienced episodic disability, characterized by fluctuating periods of feeling healthy and unwell which influenced their experiences with exercise. Living with HIV was viewed as having its own set of consequences related to i) symptoms and treatments that occasionally resulted in difficulties when trying to perform daily tasks. A majority of the women also revealed that in addition to living with HIV, ii) they were living with other concurrent health conditions, such as diabetes and COPD, which further contributed to their episodic disability.
i) Symptoms and treatments of HIV. Despite the women actively making efforts to take their daily HIV medication and maintain their health, adverse effects occasionally took a toll on some of their physical and mental well-being. For instance:

there's a huge correlation between the medication they put us on and depression. (P3)
Because of this, some women faced difficulty finding motivation to exercise. For example: Anything that discourages me [ One participant noted that their medication resulted in fatigue, which sometimes affected their ability to exercise:

Because of my medication, I get tired and uh so I might not have a good day with exercise. (P6)
Another participant highlighted the uncertainty associated to HIV and aging. Lack of knowledge had produced a degree of uncertainty living with HIV, which influenced engagement in exercise: As we get older, there's not a whole lot of studies. I mean, this disease has only been around for. . . 50-60 years since the cases. . . We don't know how all the men are aging, they're just starting to age now, let alone women . . . so I got to make sure I got some sort of regime in place now while I can before-before it gets the better of me. (P4) ii) Concurrent health conditions. The majority of the women in this study were living with other chronic health conditions in addition to HIV. Living with multi-morbidity interrupted certain participants from engaging in exercise as it put strain on their bodies, which further had the potential to exacerbate episodic disability living with HIV. For instance, one participant noted:

Sense of belonging.
Having a sense of belonging within the HIV community, or lack thereof, could encourage or deter a woman from engaging in exercise. Women expressed the importance of finding a sense of belonging within a community when dealing with the challenges related to HIV. Sense of belonging was comprised of i) a lack of community that discouraged women to exercise, ii) a racial divide within certain spaces, and iii) having a support network that garnered motivation to exercise.
i) Lack of community. One participant agreed that being part of a group would motivate her to exercise, but she struggled to find a community group within the multiple sub-groups of people living with HIV: iii) Support network. Conversely, some women claimed they found a support network (i.e., fitness instructor and/or exercise class) who encouraged them to get involved and remain consistent with exercise:

by yourself, it's hard [to exercise consistently]. But, with a teacher, that is the reality. With a teacher, you go there and let's go! Put the music and everyone is doing and there is different level, but your power, you have to do it. (P7)
The role of support as promoting engagement in exercise was reiterated by another participant:

I maintain that one-day a week [of group-based exercise] 'cuz I know that there's somebody else that I can go with and things like that, it's accountability. (P4)
Perceptions of exercise. Each participant had different perceptions of exercise, which influenced the role it played in their life. Perceptions of exercise was comprised of i) exercise as a priority, ii) exercise as health promotion that could prevent secondary disease with aging and multi-morbidity, and iii) understanding the terminology between 'physical activity' and 'exercise' can promote exercise among women living with HIV.
i) Exercise as a priority. Some participants expressed exercise as a luxury (i.e., financial, time, energy) rather than a priority, which largely became non-attainable to them. This meant some participants rarely, if at all, engaged in exercise or were limited in how much or how often they could exercise. As one woman expressed, some did not view exercise as an important factor in their life: Working out is not. .

. it's a luxury. It's not a privilege. It's a luxury. And, because of that, a lot of people don't work out. (P3)
Living with a mental health condition, such as depression, made exercising difficult to achieve for some women. Lacking motivation to become active resulted in this participant avoiding exercise:

I'm lazy and I need some motivation. . .. I have depression issues and it's kind of hard to snap out of and go think about going to work out. . . (P10)
Alternatively, those who viewed exercise as an integral part of their life, made exercise a priority. Some participants expressed they were self-motivated, and refused to accept excuses for not exercising; irrespective of environmental or personal factors, they engaged with exercise to remain healthy. For instance, one woman stated: Some women also considered themselves 'exercisers' even though they did not achieve the CSEP guidelines. This woman, for instance, after being informed of the terms, realized this during the interview: just when I was thinking I was exercising, I wasn't really. (P10) However, participants stated that knowing the differences between the terms 'exercise' and 'physical' activity could help when recommending exercise for women living with HIV, and provide direction on how to achieve the physical activity guidelines

Yes, it's good to know the term[s] and to know which is-what is because it's make more clearly for you what you need to do. (P7)
Facilitators and barriers to exercise. Facilitators and barriers included factors that influenced engagement with exercise among women living with HIV. Facilitators to exercise included: 1) aspirations to achieve a healthy lifestyle, 2) using exercise as a mental diversion from stressors in life, 3) having an exercise companion, 4) and receiving financial support from community-based organizations to facilitate engagement in exercise. Conversely, barriers to exercise included: 1) limited resources, such as lack of mental-health support and fitness resources, 2) financial limitations, 3) time and gym restrictions, and 4) cold winter weather conditions. See Table 3 for a description of the facilitators and barriers with supporting quotes.
Strategies for uptake of exercise. Participants described personal and organizational strategies to facilitate the uptake and sustainability of exercise among women living with HIV. Personal strategies included: 1) creating social interactions through classes to help women maintain their exercise routine and maintain accountability by having their peers to exercise along with; and organizational strategies included: 2) provision of online exercise classes, 3) raising awareness and educating the population to make informed health decisions, and 4) offering practical support, such as child-care and financial support. See Table 4 for a description of the strategies with supporting quotes.

Discussion
In this study, we explored the intersecting components that comprised experiences of exercise from the perspectives of women living with HIV in Canada. The six intersecting components include: (1) culture, (2) gender, (3) HIV-related stigma, (4) episodic nature of HIV, (5) sense of belonging, and (6) perceptions of exercise. While exploring the intersectionality of the six components was beyond the scope of this study, it is important to acknowledge that interconnecting patterns emerged between the various components. Intersectionality helps us understand that a woman living with HIV is not 'only' a woman, but can also possess other social identities that can intersect, for example: being a Black woman, a mother, a trans woman, a disabled woman, a woman with low socioeconomic status, or any other components of her identity that may generate empowerment or oppression [44][45][46]. Accordingly, an intersectional methodological approach can lead to multidimensional solutions that address the intricate conditions of women and their social identities [47].
Cultural roles and expectations articulated by ethnic minority women in this study were consistent with prior research that reported African American women are more subject to 3) Having an exercise companion • Women felt more inclined to exercise when they had encouragement from peers.
� you make uh friends and then they encourage you will come back and you will say ''I will be there next week, will you come with me?" You go again and you go again and you go again. unhealthy behaviours, including lower levels of physical activity [48,49] Moreover, racial or ethnic minority women living with HIV endure high levels of psychological distress [50] possibly due to the intersection of various social identities they embody [51][52][53]. Experiences of racism may also contribute to HIV-related stigma in women [54], with marginalized groups facing several forms of discrimination (i.e., racism, sexism, poverty) that can exacerbate HIV-

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Experiences engaging in exercise from the perspectives of women living with HIV: A qualitative study  related stigma [51,53,55]. Accordingly, an intersectional framework offers a holistic approach on understanding various stigmatized identities (i.e., racialized women living with HIV) and its effects on health outcomes [56][57][58][59] and perhaps how this may hinder women's experiences with exercise. Compared to their HIV-negative counterparts, women living with HIV are often more impacted by traditional gender norms [60], and specific social gender-related roles such as caregiving can impact self-management strategies in women living with HIV [61]. A commonly agreed upon benefit of exercise among women living with HIV also included improving their body physique [62]. Several women in this study expressed wanting to exercise in order to ''look good" by losing weight and toning their body due to lipodystrophy and atrophy attributed to HIV or associated treatments. To address these issues, offering flexible options for exercise such as online forms of community-based exercise may thus allow women to overcome barriers to exercise by engaging in exercise from the comfort of their own home.
Further, HIV-related stigma can negatively determine one's health with HIV [63,64]. Perceived risks including fear of contamination or spread of germs are barriers to exercise for people living with HIV [41]. Fear of judgement by others, as mentioned by some study participants about their fellow community members, was a barrier to exercise. This fear is reflective of HIV-related stigma [65,66]. This also mirrors the recent work of Vancampfort et al. (2021), who revealed that possessing higher levels of internalized HIV-related stigma was linked with lower levels of physical activity in people living with HIV [67]. Stigma may be experienced differently by gender as women living with HIV experienced higher rates of HIVrelated stigma compared to men living with HIV [68,69]. Researchers should further investigate the ways in which interventions on HIV stigma-reduction may enhance participation in exercise and improve health outcomes for women living with HIV [67].
With HIV being episodic in nature, it involves changing levels of health, which influences people's willingness to exercise [70]. Physical barriers to exercise among people living with HIV are characterized as side effects to HIV and HIV medication, which resulted in lipodystrophy and fatigue, breathlessness, muscular and joint pain and other conditions related to their co-morbidities [41,43,62,71]. Such health fluctuations can generate uncertainty for people living with HIV and consequently make it challenging to establish health-promoting behaviors such as exercise [70]. However, Gielen et al. (2001) found that women living with HIV who practiced health promoting behaviors like exercise described improved health outcomes and quality of life. [72] As such, exercise can help avert and mitigate the acute effects of chronic comorbidities [73][74][75][76][77], which means that the health benefits of exercise are necessary to examine in future exercise-based interventions [78]. Evidence also supports the role of health care providers to ensure exercise is a priority against chronic conditions [79] as educating women on the benefits of exercise can potentially facilitate activity [80].
As exhibited within this study, social support is a key contributor in fostering exercise and preventing barriers to exercise in people living with HIV [81], and women living with HIV who possess a strong social support system describe improvements in both their health and quality of life, as well as facilitated their engagement with exercise [72,82]. Social support is well evidenced as a facilitator for exercise and self-management strategy among people living with HIV [65,81,83,84], whereas insufficient social engagement appears to negatively affect participation in exercise among people living with HIV [85]. Similarly, Peterson (2010) stressed the importance of maintaining supportive resources as some women living with HIV did not have a community network they could depend on [86]. This further suggests that social support can positively affect adherence to exercise [87], and offer a source of empowerment and sense of belonging to women living with HIV [88,89]. As such, social support is a positive and effective addition to traditional HIV treatment methods [90][91][92].
Finally, similar to Simonik et al. (2016), participants in this study unveiled that their willingness to exercise was subjective to the perceptions they held about exercise [70]. While women acknowledged the importance of incorporating exercise into their life, many regarded it as a low priority [70]. 'Non-exercising' women may consider themselves as active individuals since their perception of exercise may be largely centered on social context [93,94]. Findings from this study indicated that some 'non-exercising' women were unaware they were considered a non-exerciser on the basis of the CSEP guidelines. It appeared women classified as 'non-exercisers' had lower expectations for exercise when viewed as a construct [93]. Providers and researchers should further study women living with HIV and their perceptions of exercise and physical activity to confirm exercise interventions meet their unique needs [95].

Strengths and limitations
This study presents several limitations. Purposive sampling allowed us to explore diverse experiences and perceptions of women who engaged or did not engage in exercise. Recruitment challenges resulted in a smaller than anticipated sample size, potentially attributed to fatigue with online meetings that took place during the COVID-19 pandemic [96] and other competing priorities of women. Nevertheless, our sample of racially diverse women was representative of the larger population of women living with HIV enhancing transferability of study findings [97]. Finally, this study was specific to women living in Toronto, a large urban centre in a high-income country, with access to technology, making it difficult to transfer finding with women living with HIV in rural areas with limited access to technology.

Conclusions
Experiences with exercise among women living with HIV were characterized by six intersecting components: gender, culture, episodic nature of HIV, HIV-related stigma, sense of belonging and perceptions on exercise. Facilitators to exercise included: aspirations to achieve a healthy lifestyle; using exercise as a mental diversion from stressors in life; having an exercise companion; and receiving financial support from community-based organizations. Barriers to exercise included: limited resources; financial limitations, time and gym restrictions; and winter weather conditions. Strategies to facilitate the uptake and sustainability of exercise, included: creating social interactions through classes to help women maintain their exercise routine and maintain accountability by having their peers to exercise along with; provision of online exercise classes; raising awareness and educating the population to make informed health decisions; and offering practical support, such as child-care and financial support. Results from this study will help to inform the future tailored implementation of exercise as a rehabilitation strategy for women living with HIV in the community.